Ineffective esophageal motility (IEM) is a physiologic diagnosis and is a component of the Chicago Classification. It has a strong association with gastroesophageal reflux and may be found during work-up for anti-reflux surgery. IEM implies a higher risk of post-op dysphagia if a total fundoplication is done. We hypothesized that IEM is not predictive of dysphagia following fundoplication and that it is safe to perform total fundoplication in appropriately selected patients.
Retrospective chart review of patients who underwent total fundoplication between September 2012 and December 2018 in a single foregut surgery center and who had IEM on preoperative manometry. We excluded patients who had partial fundoplication, previous foregut surgery, other causes of dysphagia or an esophageal lengthening procedure. Dysphagia was assessed using standardized Dakkak score???40 and GERD-HRQL question 7???3.
Two hundred patients were diagnosed with IEM and 31 met the inclusion criteria. Median follow-up 706days (IQR fundoplication.
In appropriately selected patients, when total fundoplication is performed in the presence of preoperative IEM, the rate of long-term postoperative dysphagia is similar to the reported rate of dysphagia without IEM. With appropriate patient selection, total fundoplication may be performed in patients with IEM without a disproportionate increase in postoperative dysphagia. The presence of preoperative IEM should not be rigidly applied as a contraindication to a total fundoplication.Peroral endoscopic myotomy (POEM) has been shown to be effective for achalasia patients. Our study aimed to analyze the clinical outcomes of POEM for challenging patients.
We retrospectively enrolled 278 challenging achalasia patients who underwent POEM from January 2011 to July 2019. The outcomes of POEM such as procedure time, adverse events, and risk factors of adverse events were analyzed.
Of the 278 patients (134 males and 144 females) with a mean age of 47.0years, 103, 223, 93, and 98 patients had prior treatment and were Ling classification IIc/III, submucosal fibrosis (SMF) classification 2/3, and esophageal mucosa in achalasia (EMIA) classification c/d/e/f, respectively. The mean procedure time was 45.9min (range, 15-158min). The mean length of the tunnel and myotomy were 10.1cm (range, 7-17cm) and 6.6cm (range, 5-13cm), respectively. The major adverse event rate was 14.1%, while the minor adverse event rate was 4.7%. SMF classification 2/3 was an independent risk factor for incomplete tunnelinundoplication.Third space endoscopy technique facilitates therapeutic endoscopy in subepithelial space. This study aimed to investigate peroral endoscopic tumor resection (POET) with preserved mucosa technique for upper gastrointestinal tract subepithelial tumors (UGI-SETs) removal.
Between February 2011 and December 2019, consecutive patients with SETs of esophagus and stomach who underwent POET for enlarging size during follow-up, malignant endoscopic ultrasound features or by patient's request were enrolled. https://www.selleckchem.com/products/cpi-0610.html Demographic, endoscopic and pathological data were analyzed retrospectively.
Totally 18 esophageal (mean?±?SD age, 55.23?±?4.15year-old, 38.89% female) and 30 gastric (52.65?±?2.43year-old, 53.33% female) SETs in 47 patients (one with both esophageal and gastric lesions) were resected. The mean (±?SD) endoscopic/pathological tumor size, procedure time, en-bloc/complete resection rate, and hospital stays of esophageal and gastric SET patients were 12.36 (±?7.89)/11.86 (±?5.67) and 12.57 (±?6.25)/12.35 (±?5.73) mm, 14.86 (±?6.15) and 38.21 (±?15.29) minutes, 88.89%/94.44% and 86.77%/93.30%, and 4.14 (±?0.21) and 4.17 (±?0.20) days, respectively. The overall complication rate was 18.75%, including 6 self-limited fever and 3 pneumoperitoneum relieved by needle puncture. There was no mortality or recurrence reported with mean follow-up period of 23.74 (±?4.12) months.
POET is a safe and efficient third space endoscopic resection technique for removal of UGI-SETs less than 20mm. Long term data are warranted to validate these results.
POET is a safe and efficient third space endoscopic resection technique for removal of UGI-SETs less than 20 mm. Long term data are warranted to validate these results.Jejunojejunal intussusception (JI) is a serious but rare complication that may occur following Roux-en-Y gastric bypass (RYGB) surgery. Causes of JI and best management strategy are not clearly defined.
Electronic health records were queried for ICD 9/10 codes for intussusception after RYGB surgery (2009-2019), and charts retrospectively reviewed. Patient demographics, operative technique, presentation, radiology, and JI management were analyzed.
Of the 2,327 RYGB patients identified at our institute, 34 (1.5%) were treated for JI. The mean age was 45.0?±?8.6years, mean BMI (RYGB surgery) was 43.1?±?8.2kg/m, mean BMI at JI was 28.3?±?5.8kg/m, and 30/34 were female, The mean time between RYGB and JI was 5.5?±?4.3years (range 1-17years). Of the JI patients identified, 9 had operative notes that did not include jejunojejunostomy linear stapler length (JJ-LSL). Of the remaining 25 JI patients, 9 had a 60-mm JJ-LSL and 16 had a 120-mm JJ-LSL. Rate of intussusception was higher in the 120-mm versus 60-mm 
In our experience, JI appears to be a relatively rare complication after RYGB surgery. However, for patients developing JI, the majority had a JJ length???120 mm, and most patients required operative management which was associated with a higher rate of conversion to open and risk of JI recurrence. Reduction only technique had the highest risk of JI recurrence and therefore is not recommended.Lck is a Src-related protein tyrosine kinase that associates with CD4 and CD8 molecules and is essential to T cell development and T cell activation. Regulatory mechanisms of Lck are diverse and controversy exists regarding the importance of each mechanism. The balance of phosphorylation at the inhibitory and activating Tyr residues is maintained by a balance between CD45 and Csk and is dependent upon intact intracellular trafficking machinery. Current evidence shows that lipid-binding changes depending on Lck conformation and that phosphorylation-induced conformational changes in Lck modulate its kinase activity potentially through regulation of Lck clustering at the plasma membrane. Downstream regulators such as ZAP-70 mediate negative feedback that is dependent on Tyr192 phosphorylation. This review examines the diverse regulation of Lck in detail, highlighting the role of each mechanism on maintaining an appropriate amount of Lck in each conformational state, thus allowing for an efficient, appropriate, and controlled amount of T cell activation following TCR stimulation.